Medical Problem 1. Hyperglycemia/Diabetes 1. Not controlled post prandial 2. Fasting? 3. BG 200-280 4. A1C 8.2 5.

Drinking and urinating a lot 6. No hypoglycemia 2. Hypertension 1. Insufficiently treated 2. erratic 3. 140s/90s 4. With diabetes, should be 130-85 3. Heart Failure 1. Systolic (right side?) Compensated 2. Low EF 3. Exercise Intolerance 4. Symptoms Controlled 5. No edema 4. Obesity 1. BMI 32.1 5. Hypercholesterolemia 1. Reasonably controlled Drug Reconciliation Lisinopril 5mg = HF/HTN Metoprolol 100mg qd = HF/HTN Furosemide 40mg qd = Edema Metformin 500mg bid = Diabetes Drug Related Problems 1. DOE Beta Blockers 2. Non-cardioselective beta blockers can cause increased bg (metoprolol shouldn't be a problem) Additional Information not in the case that would be of value FBG Urine Ketones Changes in weight Blood pH

Hyperglycemia Type II DM SMBG 200-280 post prandial BG 234 Polydipsia polyurea polyphagia not specified Weight change not specified neg for acidosis no sob Dyspnea on exertion no muscle pain/weakness ketone bodies unknown (Ketoacidosis) No Hemodynamic instability (Lactic acidosis no palpitation no renal dsyfunction BUN WNL Albumin WNL SrCr WNL CC: Ms Julia Wilson, a 54 yo obese woman with Type II Diabetes complains that her BG is out of control with 200-280mg/dL post prandial for the past two weeks. Patient demonstrates noticable fatigue and reports polydipsia, polyurea and noctureia 3 times per night.. PE negative for signs of stroke, visual changes. Patient denies hypoglycemic episodes. Patient has DOE after walking 2 blocks. PMH: Patient was diagnosed with Type II Diabetes 4 years ago. Patient also has ACC/AHA Stage C, NYHA Stage II HF, Stage I HTN, and Hyperlipidemia. FMH: Patient's mother and 2 brothers have diabetes. Mother died of breast cancer one year ago. Her father died of a MI at 53yo. SH: Patient's use of nicotine and alcohol were unavailable. Patient has a poor diet and rarely exercises, which she blames on her shift work. Objective Allergy information unavailable. BP (142/92,144/88, 146/90) HR 70 PE negative for symptoms of stroke, CAD, arrhythmia, edema, and respiratory problems. Labs from 10/5/07 unremarkable except for Lipids, A1C 8.2%, and Blood Glucose 234mg/dL. TG 167mg/dL, Cholesterol 178mg/dL, HDL 40gm/dL, LDL 94mg/dL. Current Medications: Lisinopril 5mg PO QD Metoprolol Succinate 100mg po QD Furosemide 40mg po QD Simvastatin 40mg po QD Metformin 500mg BID

Possible Treatments

Current Treatments Metformin 500mg PO BID Pharmacological options Increase to Metformin 1000mg PO BID. Metformin is the consensus first line treatment for Hyperglycemia to lower FBG. Her current dose is still below the maximum effective dose of 2000mg/day. The drawback to a Metformin increase in the increased risk of Lactic Acidosis. This risk is low with Metformin vs. Fenformin. Patient would require continued monitoring for renal dysfunction. Adding a sulfonylurea such as Glyburide would also provide a reduction in FBG and A1C. Add on sulfonylurea therapy significantly increases the risk of hypoglycemia. The weight gain associated with sulfonylureas may also be a concern. The increased risk of edema with thiazolindinediones make them a poor choice for add-on therapy. Beginning basal insulin therapy is a good choice if intensive therapy is required or three agent oral therapy has failed (AACE Guidelines). Patient acceptance and compliance are issues with initiating insulin therapy. Initial therapy would involve QHS dosing of NPH or glargine insulin, titrating to FBG <100mg/dL. Non-Pharmacological TLC *Begin DASH diet to lower post-prandial blood glucose by controlling carbohydrate consumption. *Initiate exercise program, progressing to moderate exercise for 30-60 minutes 3-5 days per week. Exercise has been demonstrated to increased insulin sensitivity, Assessment Patient has uncontrolled Type 2 DM, as demonstrated by acute hyperglycemia and recently elevated A1C of 8.2%. In accordance with AACE Guidelines for patients currently treated, the patient should begin combination oral therapy. Metformin should be increased to the maximum effective dose of 1000mg PO BID. Glyburide should be started at 2.5mg po QD, with the goal of titrating to the maximum effective dose of 20mg po daily. Hemodynamicly unstable heart failure increases the risk of Lactic Acidosis with metformin. Patient is currently hemodynamically stable with no signs of edema or kideny dysfunction. Nonetheless, the patient should be monitored for signs of Lactic Acidosis. The addition of Glyburide also increases the risk of hypoglycemia, so the patient should monitor her blood glucose regularly and counseled on sign of hypoglycemia. Combination products of Metformin and Glyburide are available if the pill burden is troubling to the patient. Patient should monitor BG closely while titrating Metformin and Glyburide. The patient could also increase her insulin sensitivity by adding regular exercise. The patient should also begin following a diabetes-friendly diet, such as the DASH diet.

Her current therapy of metoprolol 100mg QD may have some effects on her blood glucose, but should be continued due to benefits in patients with HF. Goals Per ADA Standards of Medical Care *Eliminate hyperglycemia symptoms *Maintain FBG of 90-130mg/dL *Reduce Post-Prandial BG to <180mg/dL *Reduce A1C <7.0% Plan *Increase to Metformin 1000mg BID *Initiate Glyburide 2.5mg po QD *Patient to begin walking 30 minutes 3x/week *Patient to begin DASH Diet *Patient to monitor FBG Post Prandial BG (QID testing) *Followup visit in two weeks to check SBGM Education *Inform patient of potential for GI upset with Metformin. *Patient should self monitor weight and report any changes in weight to the clinic *Inform patient of risk of Lactic Acidosis due to increased Metformin dose(Dyspnea, Myalgia, Malaise, Altered Metal Status, Palpitations) *Inform patient on increased risk of Hypoglycemia due to Glyburide (Altered Mental Status, sweating, palpitations, sudden hunger, headache) *Inform the patient to contact the clinic at the first signs of Lactic Acidosis or Hypoglycemia *Provide the patient with an exercise logbook *Provide the patient with the DASH diet handbook and recipe websites Efficacy Monitoring *FBG daily with a goal of 100mg/dL *PPBG TID with a goal of 90-140mg/dL *Pharmacist review of SBGM in two weeks *A1C in three months with a goal of <7.0% Safety Monitoring *Chem 7 to monitor for Lactic Acidosis and Hypoglycemia monthly or if patient reports symptoms of either. Sodium, potassium SCr, BUN, Glucose should all be WNL *Patient weight should be monitored as a precaution against hemodynamic instability. Changes in weight of over 3 lbs are a warning sign of hypervolemia. *FBG and PPBG monitoring for Hypoglycemia (<76mg/dL) Drug Drug Interactions Metformin-Glyburide has an increased risk of Hypoglycemia

Hypertension

CC: Ms Julia Wilson, a 54 yo obese woman with blood pressure exceeding 140/90 on three consecutive visits. Patient has DOE after walking 2 blocks. PMH: Patient was diagnosed with Type II Diabetes 4 years ago. Patient also has ACC/AHA Stage C, NYHA Stage II HF, Stage I HTN, and Hyperlipidemia. FMH: Patient's mother and 2 brothers have diabetes. Mother died of breast cancer one year ago. Her father died of a MI at 53yo. SH: Patient's use of nicotine and alcohol were unavailable. Patient has a poor diet and rarely exercises, which she blames on her shift work. Objective Allergy information unavailable. BP (142/92,144/88, 146/90) HR 70 PE negative for symptoms of stroke, CAD, arrhythmia, edema, and respiratory problems. Labs from 10/5/07 unremarkable except for Lipids, A1C 8.2%, and Blood Glucose 234mg/dL. TG 167mg/dL, Cholesterol 178mg/dL, HDL 40gm/dL, LDL 94mg/dL. Current Medications: Lisinopril 5mg PO QD Metoprolol Succinate 100mg po QD Furosemide 40mg po QD Simvastatin 40mg po QD Metformin 500mg BID Current Regimen Lisinopril 5mg PO QD Metoprolol Succinate 100mg po QD Furosemide 40mg po QD Pharmacological Increase Lisinopril to target dose of 10mg daily. ACEI have been demonstrated to reduce morbidity and mortality in HF patients, reduce blood pressure, and increase exercise tolerance. Side effects of hyperkalemia and hypotension increase with increasing dose and should be monitored. Increase Metoprolol succinate to target dose of 200mg daily. Cardioselective Beta Blockers have both cardioprotective effects and reduce blood pressure. Relevant side effects are risks of bradycardia and masking of hypoglycemia. Diuretics are not indicated because patient is managing fluid levels with furosemide. Digitalis Glycoside is only warranted in patients with repeated hospitilizations and poor symptom control. Non Pharmacological The DASH diet may help reduce blood pressure by reducing dietary sodium intake.

Initiate exercise program, progressing to moderate exercise for 30-60 minutes 3-5 days per week. Exercise has been demonstrated to reduce systolic and diastolic blood pressure.

HPI Asessment Patient has uncontrolled Stage I hypertension. JNC recommends patient with diabetes maintain a BP of <130/85mmHg. The patient's existing therapy of Lisinopril and Metoprolol Succinate can be increased to synergistically reduce long term risk of HF morbidity and mortality and reduce her blood pressure. Both Lisinopril 5mg daily and Metoprolol Succinate 100mg daily are below target doses. Doubling the daily dose of each will bring them to target doses. A more aggressive therapy is indicated, as the patient needs a minimum SBP reduction of 15mmHg. Increasing the Lisinopril dose may have the added benefit of reducing the patient's DOE. The risk of masking hypoglycemia is of moderate concern with the concurrent addition of glyburide (see Hyperglycemia SOAP). The patient should be counseled on this risk. Risks of bradycardia (HR <50) and hypotension are low. Additional agents are not indicated until these agents are optimized. Patient should begin the DASH diet and start a program of moderate exercise 30-60 minutes per day 35 days per week. Both diet improvements and moderate, regular exercise reduce blood pressure. Self blood pressure and heart rate monitoring should be initiated. Goals *Reduce BP to <130/88mmHg in accordance with JNC 7 Hypertension Guidelines Plan *Increase to Lisinopril 10mg PO daily *Increase to Metoprolol Succinate 200mg PO daily *Initiate DASH Diet *Patient to begin walking 30 minutes 3x/week *Daily patient BP and HR monitoring & logging *Follow up with patient in 2 weeks to check blood pressure Education *Inform patient of hyperglycemia masking risk (sweating will be the only remaining sx). Emphasize the importance of monitoring BG per diabetes plan. *Inform the patient of the minor risks of hypotension and bradycardia *Instruct the patient on proper BP and HR monitoring technique *Provide the patient with an exercise logbook *Provide the patient with the DASH diet handbook and recipe websites Efficacy Monitoring *Patient monitoring of BP <130/85mmHg *Clinic BP monitoring <130/85mmHg in two weeks and at all subsequent visits

Safety Monitoring *Patient monitoring of HR. Monitor for Bradycarida HR<60BPM *Clinic BP monitoring <130/85mmHg in two weeks and at all subsequent visits *FBG and PPBG monitoring for Hypoglycemia (<76mg/dL) Drug-Drug Interactions Lisinopril-Metformin has a moderate risk of hypoglycemia